Fibromyalgia in Perspective For several centuries, muscle pains have been known as rheumatism. 1816 – Dr. William Balfour, surgeon at Univ of Edinburgh: first full description of fibromyalgia. 1824 – Described tender points. 1904 – Sir William Gowers coined the term fibrositis, literally “inflammation of fibers”. 1972 – Dr. Hugh Smythe laid the foundation for the modern definition of fibromyalgia by describing widespread pain and tender points. 1987 – The American Medical Association recognized fibromyalgia as a real physical condition. 1990 – The American College of Rheumatology (ACR) developed diagnostic criteria for research purposes.

Earliest Recorded Case of Fibromyalgia?

Job's physical anguish described in the Bible was probably the earliest description of a fibromyalgia-like condition. “I, too, have been assigned months of futility, long and weary nights of misery. When I go to bed, I think, 'When will it be morning?' But the night drags on, and I toss till dawn…And now my heart is broken. Depression haunts my days. My weary nights are filled with pain as though something were relentlessly gnawing at my bones.” -Job 7:3-4 and 30:16-17 – NLT.

1990 American College of Rheumatology Definition of Fibromyalgia Syndrome 1. History of widespread pain for more than 3 months. Definition. Pain is considered widespread when all of the following are present: pain in the left side of the body, pain in the right side of the body, pain above the waist, and pain below the waist. In addition, axial skeletal pain (cervical spine or anterior chest or thoracic spine or low back) must be present. In this definition, shoulder and buttock pain is considered as pain for each involved side. "Low back" pain is considered lower segment pain.

Digital palpation should be performed with an approximate force of 4 kg. For a tender point to be considered "positive" the subject must state that the palpation was painful. "Tender is not to be considered "painful."

Tender point sites of the 1990 American College of Rheumatology criteria for fibromyalgia.

Objective. To develop simple, practical criteria for clinical diagnosis of fibromyalgia that are suitable for use in primary and specialty care and that do not require a tender point examination, examination and to provide a severity scale for characteristic fibromyalgia symptoms.

Methods.We performed a multicenter study of 829 previously diagnosed fibromyalgia patients and controls using physician physical and interview examinations, including a widespread pain index (WPI), a measure of the number of painful body regions. Random forest and recursive partitioning analyses were used to guide the development of a case definition of fibromyalgia, to develop criteria, and to construct a symptom severity (SS) scale. Results.Approximately 25% of fibromyalgia patients did not satisfy the American College of Rheumatology (ACR) 1990 classification criteria at the time of the study. The most important diagnostic variables were WPI and categorical scales for cognitive symptoms, unrefreshed sleep, fatigue, and number of somatic symptoms. The categorical scales were summed to create an SS scale. We combined the SS scale and the WPI to recommend a new case definition of fibromyalgia: (WPI >7 AND SS >5) OR (WPI 3–6 AND SS >9). Conclusion.This simple clinical case definition of fibromyalgia correctly classifies 88.1% of cases classified by the ACR classification criteria, and does not require a physical or tender point examination. The SS scale enables assessment of fibromyalgia symptom severity in persons with current or previous fibromyalgia, and in those to whom the criteria have not been applied. It will be especially useful in the longitudinal evaluation of patients with marked symptom

2010 ACR Proposed FMS Criteria A patient satisfies diagnostic criteria for fibromyalgia if the following 3 conditions are met: 1) Widespread pain index (WPI) >7 and symptom severity (SS) scale score >5 or WPI 3–6 and SS scale score >9. 2) Symptoms have been present at a similar level for at least 3 months. 3) The patient does not have a disorder that would otherwise explain the pain. http://www.rheumatology.org/practice/clinical/classification/fibromyalgia/2010 _Preliminary_Diagnostic_Criteria.pdf#search=%22fibromyalgia%20criteria %22

Widespread Pain Index 1) WPI: note the number areas in which the patient has had pain over the last week. In how many areas has the patient had pain? Score will be between 0 and 19. Shoulder girdle, left

Hip (buttock, trochanter), left

Jaw, left

Upper back

Shoulder girdle, right

Hip (buttock, trochanter), right

Jaw, right

Lower back

Upper arm, left

Upper leg, left

Chest

Neck

Upper arm, right

Upper leg, right

Abdomen

Lower arm, left

Lower leg, left

Lower arm, right

Lower leg, right

SS scale score:

Symptom Severity Scale

●

Fatigue

●

Waking unrefreshed

●

Cognitive symptoms

For the each of the 3 symptoms above, indicate the level of severity over the past week using the following scale: ●

The SS scale score is the sum of the severity of the 3 symptoms (fatigue, waking unrefreshed, cognitive symptoms) plus the extent (severity) of somatic symptoms in general. The final score is between 0 and 12.

Alternative Criteria A. Generalized pain affecting the axial, plus upper and lower segments, plus left and right sides of the body.

Plus, Either B or C: B. At least 11 of 18 reproducible tender points C. At least 4 of the following symptoms: 1. Generalized fatigue 2. Generalized headache (of a type, severity, or pattern that is different from headaches the patient may have had in the premorbid state) 3. Sleep disturbance (hypersomnia or insomnia) 4. Neuropsychiatric complaints (1 or more of the following: forgetfulness, excessive irritability, confusion, difficulty thinking, inability to concentrate, depression) 5. Numbness, tingling sensations 6. Symptoms of irritable bowel syndrome (periodically altered bowel habits with lower abdominal pain or distension usually relieved or aggravated by bowel movements; no blood) D. It cannot be established that the disturbance was caused by another systemic condition Adapted from Pope HG Jr, Hudson JI. A supplemental interview for forms of “affective spectrum disorder.” Int J Psychiatry Med 1991;21:205–32;

FIQR scoring There are just 3 steps: Step 1. Sum the scores for each of the three domains (function, overall, and symptoms). Step 2. Divide domain 1 score by three, divide domain 2 score by one (that is, it is unchanged), and divide domain score 3 by two. Step 3. Add the three resulting domain scores to obtain the total Revised Fibromyalgia Impact Questionnaire (FIQR) score. Scoring Total: It is scored from 0 to 100 with the latter number being the worst case. The average score for fibromyalgia patients seen in tertiary care settings is about 55. The lower the score, the better the case.

http://www.myalgia.com/FIQR/Scoring.htm

Cognitive Domains Related to FMS/CFIDS ●

●

●

●

●

Executive Functioning (planning, organizing, inhibition of behavior, error detection, insight) Attention (focus on specific stimuli to the relative exclusion of others) Memory (encoding, recall, recognition) Working Memory (temporary storage and management of information) Processing Speed (rate of processing stimuli and making use of it in thought and action)

Neurocognitive complaints ●

Memory impairment

●

“Fibro Fog”

●

Coordination

●

Balance

●

Concentration

●

Word substitution

●

Executive function

Qualitative Studies in FMS ●

●

●

●

Greatest impact on quality of life included pain, sleep disturbance, fatigue, depression, anxiety, and cognitive impairment Primary reported cognitive effects were on memory, thought processes, planning/organization, response time, word-finding and concentration These impairments have collectively been referred to by patients as “fibro fog” “Fibro fog” is reported to affect a wide range of activities including driving, social interactions, and work-related tasks

Blog Sites O Tender Brain, my complaints were undue! I didn't realize you were suffering too. We'll work together to win this fight with every weapon available in sight. Botox, Savella, PT and nerve blocks, The solution to fibro -- you and I will unlock. -- Written by Dot and Fibro Mom (representing Dot's

Barriers to Treatment: Patient Perspective 1. Medical treatment and medical providers are ineffective and uncaring, respectively. 2. Pain pills are the only allopathic option that works. Give me my Vicodin! 3. Give me massage. I might like acupuncture. How about a hot tub? Will the chiropractor help? Can somebody fix me? 4. I read about a cure on the internet.... 5. Psychologists, psychiatrists and counselors are for crazy people. Your referral means you think I’m crazy and it’s all in my head. I'm not depressed. I'm insulted. 6. Exercise hurts and I’m not going to do it. 7. I can't sleep unless I have the TV on.